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KENORA — A highway billboard 40 kilometres east of Winnipeg features a young woman waterskiing next to the warning, “Leaving Manitoba? You need travel insurance.”

This image captures the Lake of the Woods experience as the summer playground for Winnipeggers who can afford cottages across the Ontario border.

For those living in northwestern Ontario, the Manitoba border also presents a health care access obstacle — one that medical leaders have been urging governments to overcome.

The Canada Health Act ensures provinces give their own residents priority treatment — but it doesn’t prevent them from refusing cross-border patient referrals. Some border communities located far from their province’s large population centres have been granted exceptions to this rule via interprovincial agreements: Manitoba and Saskatchewan agreed in 1981 to allow Flin Flon residents access to medical services across the border. Ontario signed a similar agreement with Quebec in 1989, allowing patients in the Gatineau area to receive care in Ottawa.

But no such accord exists between Ontario and Manitoba. Kenora is about 50 kilometres from the Manitoba border. But its residents requiring specialist services must go to Thunder Bay — 500 kilometres eastward — to get them, even though Winnipeg is just 200 kilometres away. Complex care cases, such as cardiac surgery and neurosurgery, can be sent nearly 2,000 kilometres away to London, Ottawa, or Toronto.

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Aging populations requiring more frequent and complex care on both sides of the border have strained Manitoba’s health care system.

A decade ago, 90 per cent of Kenora’s out-of-town referrals went to Winnipeg. Half of those patients are now referred to southern Ontario, especially if they need stroke or cancer treatment, which require highly specialized equipment and staff.

But the increased need for health care means the number of Ontario patients served in Manitoba’s hospitals has remained constant since 2010. In an average year, the Ontario government pays Manitoba $29 million for 12,000 of its residents to access health care in Winnipeg.

In early 2016, the Winnipeg Regional Health Authority sent a memo informing Ontario physicians in the northwest that its hospitals no longer had the capacity to accept a wide range of referrals — including pediatric, adult critical care, internal medicine, surgical, cardiac, and neo-natal and pediatric ICU patients. Five years earlier, Manitoba denied service to non-emergency cardiac patients from Ontario.

“What they say in this memo is, ‘Unless it’s life or limb,’ but the physicians you talked to would say, ‘We have this memo. We can’t accept this patient,’ but they’d forget the life or limb part,” says Jillie Retson, a physician based in Kenora. “The intention wasn’t to refuse life and limb cases, but occasionally, it did happen.”

Retson says lives were lost in the process. She won’t guess how often patients were rejected, but says some of her colleagues stopped asking Winnipeg hospitals for service in the interest of saving time.

“If you’re trying to decide how to make health care accessible, I think the portability side of things trumps everything else,” says Sean Moore, Lake of the Woods District Hospital’s chief of emergency services. “Patients should go where they’re best treated and most effectively treated. Most times for acute injuries, that’s the closest centre and that’s Winnipeg for most centres in northwestern Ontario.”

The access issue extends beyond emergency care. LWDH president Mark Balcaen says many patients — particularly the elderly — who suffer strokes or undergo orthopedic surgeries forgo rehabilitation treatment in Thunder Bay due to the strain of travel, distance from loved ones, and the cost of several weeks’ accommodations. Were those services available in Winnipeg, he says, daily travel would be possible.

Retson approached Kenora city council in 2015 with a strategy to improve local health capacity and find a solution for northwestern Ontarians seeking care in Winnipeg. She proposed forming a physician-attraction committee and making cancer care available in Kenora. Her pitch resulted in the creation of the Kenora Area Health Access Group that same year.

“Kenora physicians deserve to have a web of specialist colleagues on whom they can count for advice and referrals,” says its co-chair Dennis Wallace. “With the gated system that is in place, one week patients can be referred and other weeks they cannot.”

Last September, Manitoba’s deputy health minister, Karen Herd, wrote to the Ontario Ministry of Health and Long Term Care, pledging to work with them to improve access for northwestern Ontarians. She also announced the team Manitoba would send to negotiate a funding and accountability agreement between the provinces intended to replace the existing interprovincial billing agreement.

In the meantime, some services have improved. Manitoban physicians can now order PET scans for Ontario patients. A new helicopter landing pad at the Winnipeg Health Sciences Centre has reduced transportation time between Kenora and Winnipeg by nearly half.

“They are listening now,” Retson says, adding that the Winnipeg Health Authority is “working out details — and the provinces are too. I don’t want to do anything to damage that. At the same time, this is what it took to get this.”

Still, northwestern Ontario’s health care providers want assurance that whatever centre is chosen for their patients, it’s prepared to accept them as a responsibility, not as a favour.

Michael Kirlew, a physician in Sioux Lookout, says Winnipeg has never been a reliable avenue for accessing youth psychiatric care — even in cases of life and limb — and Thunder Bay is stretched to capacity.

Kirlew, who works with a number of remote First Nations facing suicide crises, wants a commitment from someone in writing.

“We’re facing this health care crisis in our region and I believe a lot of what’s driving this is that there’s no system,” he says. “It’s not an issue of the care they’re receiving. It’s a matter of who’s responsible for them, as a region. If they’re too sick for Thunder Bay, who is going to accept them? Who can’t tell that doctor, ‘No?’”

This is one in a series of stories about issues affecting northwestern Ontario. It's brought to you in partnership with Confederation College of Applied Arts and Technology.

Ontario Hubs are made possible by the Barry and Laurie Green Family Charitable Trust & Goldie Feldman.